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Based on observation, interview and record review, the facility failed to review and revise/update the Master Treatment Plan of 1 of 8 active sample patients (Patient P4). This patient eloped twice from the inpatient unit. The treatment plan was not updated in a timely way to increase staff protection after either elopement. Failure to conduct timely reviews/revisions of treatment plans results in plans that do not reflect patients' current treatment needs. The absence of an integrated and updated/revised treatment plan results in lack of coordinated and organized treatment. (Refer to B118)

Based on observation, record review and interview, the facility failed to provide timely reviews and revisions/updates of the Master Treatment Plan for 1 of 8 active sample patients (P4). This patient eloped twice from the inpatient unit within a 24 hour period. The treatment plan was not updated to address the first elopement which occurred on 10/17/2011, and the plan update was not available until at least 5 hours after the second elopement which occurred on 10/18/2011. Failure to conduct timely reviews and needed revisions/updates of treatment plans results in plans that do not reflect patients' current treatment needs. The absence of an integrated and updated treatment plan also results in a lack of coordinated and organized treatment.

Findings include:

A. Patient P4 was admitted on 9/26/2011. The Master Treatment Plan dated 9/29/2011 listed a diagnosis of "Schizophrenia, Paranoid type." The listed problems included "Appears confused and respond [sic] to internal stimuli...appears guarded on the unit, reported exhibiting poor self care at home, reportedly not caring for...daily care."

B. During a surveyor observation of a structured activity titled "peer interaction on the patio" on 10/17/2011 at 11:15AM, Patient P4 eloped from the courtyard area by jumping over the fence immediately surrounding the courtyard and a second fence surrounding the external perimeter of the building. The patient eloped again (from inside the inpatient unit) on 10/18/2011 around 10:45AM while on "Absence without Leave" (AWOL) precautions, defined as every 15 minute observations.

C. Observation of a treatment team meeting held on October 18, 2011 at 8:30AM (after the patient's first elopement on 10/17/11) revealed no discussion or revision/update of the treatment plan for Patient P4. The plan also was not presented for staff signatures.

D. Review of patient P4's medical record on 10/18/2011 at 10:30AM revealed no update to the Master Treatment Plan, despite the fact that there was a new physician order for "AWOL precautions" written on 10/17/11 when the patient was brought back to the unit by the police after the first elopement.

E. The facility's "AWOL packet" which includes a checklist of items to be completed by the nurse and a post elopement debriefing and follow-up form, were reviewed with RN#1 on October 17, 2011at 11:45AM. Neither form specified that an elopement from the unit would be a trigger to update the patient's treatment plan.

F. Review of Patient P4's medical record on 10/18/ 2011 at 2PM revealed no review or revisions/updates of the treatment plan.

G. In an interview on 10/18/2011 at 2:30PM, the Medical Director stated, "Treatment plan review on the patient who eloped should have been done."

H. During an interview on October 18, 2011 at 3:15PM, the DON and LPC#1 acknowledged that a patient going AWOL would meet the requirement for a treatment plan revision to be made.

I. On 10/18/2011 at 3:30PM, the Director of Nursing (DON) stated, "A treatment plan review on the patient who had eloped has not been done." During this same interview, the surveyors clarified the expectation for treatment plan reviews with the implementation of AWOL procedures. The DON stated, "A (treatment) plan should be reviewed, revised and updated as necessary within the next twenty four hour period to address the additional problem of AWOL."

J. In an interview with the DON and Licensed Professional Counselor LPC#1 on 10/18/2011 at 4:15PM, the Medical Director came into the conference room and asked whether the surveyors were aware that Patient P4 "eloped again today." Additional review of documentation regarding the elopement(s) revealed a treatment plan revision/update dated 10/17/11 and signed by MD#1 on 10/18/11. When the surveyors questioned whether the treatment plan revision/update had been developed after the patient's first elopement and prior to the second elopement, the initial response by LPC#1 was "yes." When the surveyor questioned the accuracy of this information because of the earlier reviews and reports that had shown no treatment plan updates for the patient, LPC#1 stated in the presence of the DON and the Medical Director, "I'm sorry. I guess I got confused. I had eight of these to do today and I was not here yesterday and was late today."

H. The updated treatment plan was not provided to the surveyors until 4:30PM on 10/18/11.

Based on observation, record review and staff interviews, the facility failed to assure safety for all 13 currently hospitalized patients, including 8 active sample patients (P1, P2, P3, P4, P5, P6, P7 and P8) and five non-sample patients (P9, P10, P11, P12 and P13) in two situations. First, active sample patient P4 eloped from the unit during a structured outdoor activity in the courtyard as a result of insufficient staff supervision. Staff was could not bring the patient back to the unit because they had not been properly trained on the use of keys for unlocking the outdoor courtyard gate. The same patient eloped from inside the inpatient unit the day after the first elopement; staff had failed to implement sufficient precautions to prevent the re-occurrence. Second, all 13 inpatients had potential access to hazardous chemicals/equipment not properly secured on the unit. Lack of safety oversight results in all patients being at high risk for self-harm. An IMMEDIATE JEOPARDY (IJ) situation was identified due to these safety concerns. The IJ was removed on site after the facility's plan of correction was found to be satisfactory.

Findings include:

I. Patient Elopements

A. Observations and Interviews

1. During an observation of a structured activity titled "peer interaction on the patio" on October 17, 2011 at 11:15AM, patient P4 (admitted on September 26, 2011 with "Schizophrenia, Paranoid type"), eloped from the courtyard area by jumping over the fence immediately surrounding the courtyard and a second fence surrounding the external perimeter of the building. The12 other currently hospitalized patients (P1, P2, P3, P5, P6, P7, P8, P9, P10, P11, P12 and P13) and one staff member (RT#1) were attending the structured activity in the courtyard. Several staff members not attending the activity, but who visually observed the patient's elopement through the windows from the inside of the inpatient unit, came into the courtyard area to assist in apprehending the patient. Housekeeper #1 attempted to go out of the courtyard gate to exit the area but could not open the pad-lock on the gate. Therefore, he and others needed to go back onto the unit, through the unit and out the main doors to exit. Staff was not able to exit the courtyard gate to bring the patient back because of their lack of knowledge regarding the keys necessary to open the padlock on the gate.

2. On October 18, 2011 at 10:45AM, patient P4 eloped from inside the inpatient unit (second elopement) by breaking out a window in the family visiting room with a chair and exiting via the courtyard and over the external perimeter fence as he/she had done the day before. [Information provided by Medical Director during an interview on 10/18/11 at 4:30PM]

4. In both elopement incidents noted above, the patient left the hospital grounds before the staff could bring him/her back. The police were notified of each elopement per facility policy, and they returned the patient unharmed to the inpatient unit in both incidents.

B. Record/Document Review

1. Facility policy #6-01-00, dated 08/24/2010 titled "Precautions for consumers: suicide precautions, assault precautions, fall precautions and elopement precautions" states, "General watchfulness that is required for every person who meets the criteria to be admitted to an inpatient unit, includes contact with, or at a minimum observation of all clients every 15 minutes." Section IV titled "elopement precautions" does not change the frequency of monitoring. It only states, "When a consumer is on elopement precaution, he/she will be escorted by staff when off the unit. Depending on degree of elopement risk, a consumer to staff ratio may need to be one to one or two to one."

2. Review of a form titled "Employee orientation/review competency checklist for nursing staff," provided by the DON on October 18, 2011, revealed an item titled "orient to the building" under the component "fire and safety." However, there was no evidence on the form that nursing staff is instructed on which keys, distributed at the time of new hire, provide access to the courtyard gate.

3. The employee orientation files for the RN#2 and PCA#2 (most recently hired nurse and tech) were reviewed by the surveyor in the presence of the DON. There was no documentation on either staff member's orientation review/competency checklist form that information on key use and security had been reviewed as part of the unit orientation.

C. Staff Interviews

1. In an interview on 10/17/2011 at 12PM, which included a discussion of patient P4's first elopement, the DON stated, "There should have been two staff members present with the number of patients assigned to the activity (referring to the activity in the courtyard)...the second person should have been either the second Recreational Therapy staff member or a PCA (Patient Care Associate) from the unit." The DON stated that she did not know why the scheduled activity in the courtyard was not staffed in this manner. The DON also stated, "Many patients tell us they want to go home, but with this one, (P4), since there was a change in communication [the patient mentioned wanting to go home for the first time that morning], maybe we should have looked at [P4] differently and initiated the precautions for AWOL sooner."

2. During the interview above (10/17/2011 at 12PM), when the surveyor asked the DON who had the keys to open the pad-lock to the gate in the courtyard, the DON stated, "I don't know if anyone on the unit has the key."

3. In an interview on October 17, 2011 at 1:15PM, PCA#1 was asked if he had been one of the staff who had attempted to bring patient P4 back to the unit when the patient eloped (at 11:15AM that morning). PCA#1 responded, "No, because I was assigned to do the board (every 15 minute checks) with all patient observations, so I could not go out because that would have left no one doing the observations." When the surveyor asked PCA#1 if he knew who had the key to unlock the pad-lock on the courtyard gate, he responded "I know I do (have the key), and maybe one other person, but I'm not sure."

4. In an interview on October 17, 2011 at 2PM the DON stated, "I do not know why there was only one staff in the patio (with patients during the structured outdoor activity). Usually we have two staff members."

5. On October 18, 2011 at 10:10AM, the surveyor asked PCA#1 to walk through the courtyard to the gate so he could demonstrate use of the key. PCA#1 demonstrated proper use of the key. While doing so, he stated, "I know no one knew they had the key yesterday. I guess they forgot; everyone who has the key to get on the unit has the key (meaning the key to the courtyard gate)." PCA#1 also stated, "They (staff) should know this; what would have happened if [P4] jumped over the fence and climbed into one of those trees (pointing to the trees within the doubled fenced area) and got injured? How would we have gotten the proper medical attention out there?"

6. During an interview on October 18, 2011, the Medical Director stated, "Staff should have known what keys they are carrying."

7. Additional staff interviews were held in the presence of the Director of Operational Services on October 18, 2011 between 10:05AM and 11:50AM (day after patient P4's first elopement from the unit). None of the interviewed staff (RT#1; RT#2; LPN#1; Housekeeper #1) said they had been re-educated on the keys they had available (which key accessed which lock). In response to the staff interviews, the Director of Operational Services acknowledged that no re-training on the keys had been conducted with these staff.

8. On October 18, 2011 at 2PM, The DON stated, "A new PCA is oriented by a seasoned PCA and a nurse by a seasoned nurse. However, I cannot say that I know for a fact that keys are reviewed in detail. I only know that before we give keys to new employees, a requisition is completed."

II. Potential Patient Exposure to Hazardous Chemicals/Equipment

A. Observations

1. On October 17, 2011 at approximately 12:55PM, the surveyor noted that a door labeled "CAUTION Biological Hazard/Infectious Waste" was not closed or locked. The house-keeping cart was in the closet behind the unclosed door, thus was not secured. No housekeeping or other personnel was in the area observing the closet or the cart. After approximately 5 minutes, Housekeeper #2 came to the doorway and asked if the surveyor needed something. The surveyor asked if the door is to remain unlocked and opened when the cart is in the closet and staff is not physically present. Housekeeper #2 responded, "I was at the water fountain down the hall and can see if anyone goes in the room." The surveyor noted that the water fountain is approximately 40 feet from the entrance to the housekeeping closet. It was also noted that the housekeeping closet was not in direct sight of the nursing staff in the nursing station.

2. Patient P1, admitted to unit with "Depressive Disorder NOS" on October 14, 2011, and who had a history of poor impulse control, was in the day room approximately 25 feet from the unsecured closet and housekeeping cart during the surveyor observation noted in #1 above. Immediately prior to observing the unsecured cart and closet, this patient had been in the observation area where two staff members were attempting to set limits on his/her aggressive behavior (throwing items at staff, grabbing at items in the refrigerator and screaming).

3. During a treatment team meeting held on October 18, 2011, at 8:30AM, MD#1 described patient P1 as having "poor judgment, borderline tendencies and I question if [s/he] is responding to hallucinations."

B. Staff Interviews

1. During an interview on 10/17/2011 at 1:30PM, the DON stated, "No housekeeping cart is ever to be left unattended and the door to the closet is never to be left unlocked if staff is not physically present." The DON further stated that it is the "responsibility of nursing staff to ensure that the unit safety is properly observed during patient observations." When the surveyor pointed out the location of the house-keeper and patient P1being in close proximity to the unsecured housekeeping cart and closet, the DON agreed that this was a "potentially unsafe situation to have the cart unattended due to the patient's known aggressive behaviors in the past twenty four hours."

2. In an interview on October 17, 2011 at 2:25PM, the DON stated, "That is definitely a safety issue. We have gone over with Housekeeping that the cleaning cart cannot be left unattended."

3. During an interview on October 18, 2011 at 12:30PM, Housekeeper #1, who was responsible for oversight of Housekeeper #2 on October 17-18, 2011 stated, "Staff receive training that their carts are to be within sight and reach at all times or locked in the closet because of the danger to patients and staff if chemicals were to be taken."

III. Accepted Plan of Correction for the IJ:

A. Patient Elopements

1. The treatment plan for patient P4 was revised and implemented October 18, 2011.

2. Unit boundaries were re-evaluated and changed to the following: (a) the first set of double glass doors between Unit D (inpatient) and Unit C (group therapy spaces) will remain locked at all times and patients will be accompanied to and from groups by staff to the Unit C area; and (b) courtyard activities will have at least two staff members present at all times.

3. The AWOL precautions were revised. Facility policy 6-01-00 titled "Precautions for Consumers: Suicide Precautions, Assault Precautions, Fall Precautions and Elopement Precautions" were revised to include the two levels of care -- Level I and Level II. Level I precautions include every 15 minute observations with the patient being escorted by staff when off the unit. Level II precautions include one [staff] to one [patient] or two [staff] to one [patient], and observations with documentation every 15 minutes. Level II observation will be implemented automatically for any patient who has eloped.

4. The AWOL packet checklist utilized by nursing staff was revised to include a trigger for treatment plan updates/revisions. Nursing staff training was initiated October 19, 2011 with completion target of October 21, 2011.

5. Training of staff on the unit boundaries, treatment plan requirements and AWOL precaution changes were initiated on October 19, 2011 with completion date scheduled for October 21, 2011.

6. A training program for staff on AWOL behaviors, to be conducted by the state Medical Director within one week, will include: behaviors indicating AWOL potential, verbalization indicating AWOL potential, and reaction to AWOL incidents.

7. Staff re-training on the use of keys and their access was initiated on October 18, 2011 and to be completed by October 21, 2011.

8. The Employee Orientation/Review Competency Checklist for Nursing Staff was revised to include a component for keys to be reviewed under the "orient to building" item. The checklist will have the initials of the supervisory trainer and employee identified with the date when completed.

B. Potential patient exposure to hazardous chemicals/equipment

1. The housekeeping and maintenance staff received retraining regarding the need for all housekeeping products to be attended at all times. The re-training was completed October 19, 2011.

2. Facility policy 16-00-25 titled "Infection Control for Maintenance and Housekeeping" was revised to include a new section titled "cleaning products and storage." All housekeeping and maintenance staff received training regarding the policy revision October 19, 2011. Nursing staff training on policy revision was initiated on October 19, 2011 with a completion date of October 21, 2011.

Based on record review and interviews, it was determined that the Medical Director failed to assure that the Master Treatment Plan for 1 of 8 active sample patients (Patient P4) had timely reviews and revisions/updates. Patient P4 eloped twice from the inpatient unit. The treatment plan was not updated in a timely way to provide increased staff protection after either elopement. Failure to conduct timely reviews/revisions of treatment plans results in plans that do not reflect patients' current treatment needs. The absence of an integrated and updated/revised treatment plan results in lack of coordinated and organized treatment. (Refer to B118)